Week 1-3 Flashcards
Normal Temp range: Oral
36-37.5 C
(97.7-99.5)
Normal Rectal Temp Range:
37.2- 37.6
(99-99.6)
Normal pulse range
60-100 Bpm
Average= 80
Normal Respirations
12-20/ min
Normal BP
<120/80
Elevated BP
120-129/ <80
Hypertension I
130-139/80-89
Hypertension II
> 140/ >90
Hypertensive Crisis
> 180/>120
Normal O2
> 95%
Pain:
P:
A:
I:
N:
Pattern, area, intensity, nature
Geriatric Normal temp
35-36 (95-96.8)
Geriatric normal BP
120/80, up to 160/95
Orthostatic vitals (Pulse and BP change)
Pulse: decrease of 30/ min
BP: decrease of 20 systolic
How to measure for Orthostatic hypotension
What are the risks
What is it a reflection of
Measure vitals while laying down first and then while sitting up
Risk of falls and losing consciousness
Reflection of dehydration or blood loss
If you are planning on rechecking vitals what is a reasonable time to see a significant change (for Orthostatic hypotension)
10 minutes
What to check for a skin assessment
Oral mucous membranes, turgor, skin folds, wounds/ dressings, heals, buttocks, sacrum elbow, knees, spine, color, warmth, moisture, texture, hair and IV site
The right of an individual to keep his or her information private
Privacy
The duty of anyone entrusted with health information to keep that information Private
Confidentiality
Compromise. In security or privacy of confidential into via acquisition, access, use or disclosure of use
Breach
Utilize initials only when identifying patients
Protect PHI on computers
Do not photocopy/ fax/ e-mail PHI
Access information need to complete educational assignments or fulfill student role
Remove all identifiable elements from forms
Dispose of PHI in confidential bins
No not discuss PHI in public places or via social networks
Student requirements when identifying patients
Speak quietly when discussing PHI in public areas
Avoid using names in public areas like elevators
Do not share passwords or log in names
Unnecessary sharing
Unnecessary browsing or medical record entry
Inappropriate use of social or electronic media
Discuss PHI as it applies to education and patient care
Patient safeguards for HIPPA
Sequence for removing PPE
Gloves
Goggles or face shield
Gown
Mask or respirator
Wash hands
Contact precautions
Gloves and gown for contact with patient or patient environment
Droplet precautions
Surgical mask within 3 feet of patient
Airborne precautions
No airborne/ ISO patients while in nursing school
Particulate respirator
Patient should also be in a negative pressure isolation room
Based on assumption that any blood or bodily fluid could be infectious
Perform hand hygiene
Use PPR based on expectation of possible exposure
Follow respiratory hygiene/ cough etiquette
Properly clean and disinfect
Safe sharps handling
Standard precautions
If touching blood, bodily fluids, secretions, excretions, and or non intact skin
When to use gloves
If clothing or exposed skin may be in contact with blood or body fluids
When to use gowns
If patient care activities are likely to generate splashes or sprays of blood, bodily fluids, secretions or excretions
When to use a mask and goggles/ face shield
What is the most cost effective way to prevent infection
Hand washing
When to use soap and water for hand washing (5)
Hands are visibly soiled
Before eating
After restroom
At the beginning of your shift
And if suspected C.diff pt
Sequence for putting on PPE
Gown
Mask or respirator
Googles or face shield
Gloves
Be cautious of non verbal cues (if you are looking at your watch or the door)
Active listening (silence)
Personal space
Closed vs. open ended questions
Facilitating
Making observations
Collaboration
Therapeutic communication guidelines
Medical history vs nursing history
Medical history focuses on medical diagnosis and patient conditions
A nursing history focuses on the patient’s responses to the health problem
Extensive history and physical assessment (aka head to toe)
Admission assessment
Use authority
Create distance
Medical jargon
Interrupt/ talk too much
Stereotype comments
Appear time rushed
Ask why
Don’ts during patient interaction
Biographical data, name, age etc
Chief complaint/ history of present illness
Patietns perception of status
Health history
Family health history
Admission assessment: History
Medical conditions aka Comorbidities (chronic health conditions
Infectious diseases
Childhood illness
Immunization history
Surgeries
Social history
Medications/ supplements
Alternative therapies
Review of body systems
Known allergies
Admission assessment
Evaluation of
cooperativeness
Understanding
Receptiveness
Response
Cognition and perception assessment
What to start off your physical assessment with
Observe general appearance, vital signs, and establish rapport with patient (ask permission for what you are doing)
Patient statements
Ex.
Pattern
Area
Intensity (numerical pain scale)
Nature
Subjective data
What the nurse
Sees
Hears
Feels
Smells
Ex. Vital signs
LOC
Plus ox
Objective data
Assessment done as need throughout the shift
Focused assessment
Febrile
Having a fever
Afebrile
not having a fever
Hyperthermia
Abnormally high body temperature
Hypothermia
Abnormally low body temperature
Rigors
Body created fever to fight off infection, causing shaking/ muscle tension
Radiation
Patient is hot, may uncover patient
Patient is cold, cover patient
Convection
Patient is hot, may use portable fan to cool
Patient is cold, close door and turn off fan
Evaporation
Patient is hot, cool cloth on forehead/ body to cool
Patient is cold, keep patient dry to reduce chills/ cold
Conduction
Patient is hot, use ice pack to reduce inflammation
Patient is cold, warm pack to help healing
Variance between apical/ peripheral pulses Pulse deficit
Exertional dyspnea
Conditional difficult of breath
Apnea
Lack of respirations
Visual, hearing, smell
Inspection
Touch, temp, texture
Palpación
Listening with stethoscope
Auscultation
Tapping an area with hands and listening for sound produced
Percussion
Awake and responsive
Alert
Very drowsy, falls also between care
Lethargic
Obtunded
Difficult to arouse (may be inebriated)
Stuporous
Very difficult to arouse
Comatose
Unresponsive to stimuli (unarousable)
PERRLA
Pupils even, round, reactive to light, accommodation
SBAR
Way to communicate with HCP
Situation
Background
Assessment
Recommendation
Why is it important to obtain vital signs on a patient
To establish a baseline
Tympanic temps for adults vs children
Up and back for adults vs down and back for children
How to take pulse
If HR is regular, take pulse for 15 seconds and multiply x 4= 60 seconds/ 1 min
Is irregular, apical pulse is needed, take pulse for one full min
Scale to rate pulse quality
0= absent
1+= threads, weak
2+ = normal quality
3+= bounding or full
O2 into and CO2 out of lungs
Ventilation
Exchange between blood and cells O2/ CO2
Diffusion
Distribution of RBCs/ oxyhemoglobin cells to body
Perfusion
Do geriatric respirations increase or decrease compared to adults and why?
Faster
Pain, activity, anxiety, harmonic condition
How long do you count respirations for?
Regular pattern: 30 seconds and multiple by 2
Irregular pattern 60 seconds
Use this side of the stethoscope for lower pitch sounds
Bell
Use this side of the stethoscope for high pitched sounds (heart, BP and lungs)
Diaphragm
Direct method vs indirect method of blood pressure measurement
Direct- catheter in artery
Indirect: BP cuff
Contraction phase of blood pressure (ejection)
Systole (listen for korotkoff sounds)
Relaxation phase (filling) in blood pressure
Diastole (listen to korotkoff sounds)
Mastectomy or lymph issues with limb
Hemodialysis grafts of fistulas
PICC lines in arms
IV in arms
Reasons for avoiding BP limbs
HR and blood pressure taken lying down then sitting, then standing if possible
Allow 1-3 mins between readings
(Decrease of 10mmHg SBP when upright and increase of 20 BPM may be Orthostatic)
Orthostatic vital signs
What is the significance of Orthostatic vital signs (what does it indicate)
Dehydration, blood loss
Risk for loss of consciousness and falls
Reflects the amount of hemoglobin bound with oxygen
Pulse oximetry/ O2 saturation
What is the goal after intervention for pain rating?
2
Erythema
Redness
Ecchymosis
Abnormal bruising
Hypoxia
Low oxygen, nails present round
Cherry angiomas and seborrheic keratoses
Adult normal skin variations
Dry skin and mucous membranes, skin tags, lentifiques, senile purpura, thinning hair
Normal geriatric skin conditions
